Failure to Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that grievances submitted by a resident's family regarding the resident's care were properly investigated and resolved in a timely manner, as required by facility policy. The policy states that all grievances must be reviewed, investigated, and responded to in writing within five working days, with findings and corrective actions communicated to the complainant both verbally and in writing. However, documentation revealed that grievances submitted on two separate occasions were not listed in the facility's grievance log, and there was no evidence that these grievances were investigated or that prompt efforts were made to resolve the concerns. The grievances submitted by the resident's daughter included allegations that the resident, who had diagnoses of hypertension, cerebral infarction, cognitive communication deficit, end stage renal disease, and dependence on renal dialysis, was left in soiled clothing for extended periods and was not changed in a timely manner. Additional concerns included inadequate staffing, malfunctioning call systems, and lack of consistent supervision of CNAs. The family reported repeated delays in care and lack of response to call bells, as well as concerns about the resident not being showered for several days. Despite these detailed complaints, the facility did not document any investigation or resolution efforts for these grievances. Interviews with facility leadership confirmed receipt of the grievances, but they were unable to provide evidence that the concerns were investigated or that findings were communicated to the complainant. The resident's daughter also confirmed that she had not received any written response or findings regarding her grievances, despite requesting them. This failure to follow grievance policy and to address the family's concerns constitutes a deficiency in honoring the resident's right to voice grievances without discrimination or reprisal.